CIVEO Early Intervention Form

CIVEO Early Intervention Referral
Patient / Injured Worker Details
Full Legal Name*

First NameLast Name
Patient Date Of Birth*
DD/MM/YYYY
Patient Email
example@example.com
Patient Phone Number*
Please enter a valid phone number.Format: (+61) 0000-000-000.
Injury Details
Injury*
Date Of Injury*
DD/MM/YYYY
Background Information
Injury Management Advisor/ Representative Details:*

Full Name

Phone Number

Email AddressNazione / Provincia

Email Address
Please provide your preferred appointment requirements.

We will endeavour to schedule the closest available day and time to suit your requirements and will email you with the appointment details once confirmed.
AM or PM? Choose all that apply.

AMPM
Western Australia or Queensland?

WAQLD
WA Clinics
QLD Clinics
Additional Comments/Notes
Services Requested For CIVEO (Select Multiple If Appropriate)

PhysiotherapyOccupational Therapy (Hand Therapy)Exercise PhysiologyPsychology
CIVEO Pre-Approved Early Intervention Package Includes:
- 1 x initial session + 4 x subsequent sessions. Further sessions can be provided with IMA approval.
- GP appointment with RediMed GP at the end of 5 sessions or discharge (whichever occurs first), for completion of Fitness For Duty (non-workers compensation) medical certificate.
- Comprehensive report following first session to be sent to referring IMA
- Short email following final approved session or discharge (whichever occurs first) outlining - therapy progression, request for further sessions, discharge for self management or outlining intentions for hand therapy.
- Escalation to W/C claim discussion process is via email or phone
- Consumables: No limit however must be noted on report/email or GP certificate to identify need.
- GP able to order recommended scans if deemed required/essential for management of injury
Relevant Documents/Reports

Cancelof
Please review both links below to our privacy policy prior to completing the form. https://www.redimed.com.au/privacy-policy/

https://www.redimed.com.au/terms-and-conditions/
- If multiple discipline services are required, costings will be as per each allied health service separately.
- All costings are aligned with the respective state-based Workers Compensation gazetted rates.
- Costs are inclusive of all approved consultations, consumables, communication and reports, in line with the state-based Workers Compensation gazetted rates.
- Invoicing is completed following each session and will be itemised with consult, report, communication and consumables
I have read the structure of RediMed's Early Intervention Program and understand, agree and consent to the associated early intervention package.

YesNo
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CIVEO Early Intervention Referral